NHSC National Advisory Council

Good morning. Let me begin by highlighting a few new high-water marks. The program on which you advise us has reached historic levels – in both providers in service and approved sites. With about 10,000 clinicians currently in the field, the National Health Service Corps has exceeded estimates for 2011 that we gave you as recently as June of last year, and these Corps members now serve more than 10.5 million patients from underserved communities.

So, with an investment of $1.5 billion over 5 years from the Affordable Care Act – and building on a prior infusion of $300 million from the Recovery Act – the National Health Service Corps has almost tripled in size, from 3,600 providers when the President took office. And even with a recent budget cut, we expect the Corps field strength to remain at historic levels.

The unprecedented growth of the Corps is testament to the hard work done by Becky Spitzgo and her staff in the Bureau of Clinician Recruitment and Service. Her leadership and her team’s commitment and expertise are almost unparalleled. But many of the new concepts and innovations that got us here sprang directly from this National Advisory Council – and I just want to say how much I appreciate your commitment and stewardship.

As you know, there were those in the beginning who wondered whether we could even do it – whether HRSA could meet such ambitious goals for the Corps. Not only did we meet them, we are in the midst of launching a Students to Service Loan Repayment program (known as “S2S”) for primary care physicians in residency that was first discussed with this Council.

S2S is a first step toward establishing funding priorities across NHSC disciplines, and it enhances incentives for service in hard-to-fill positions and high-needs areas. This is now a high priority across HHS, as we move toward better-tailoring our incentives to meet this mission.

S2S will provide loan repayment assistance of up to $120,000 to medical students (MDs and DOs) in their last year of training. In return, physicians commit to serve in a health professional shortage area upon completion of a residency program. These newest NHSC members may serve three years of full-time service or six years of half-time service in rural and urban areas of greatest need in exchange for the loan repayments.

Your advice on these and other programmatic features is important to us.

In fact, this Council has been a reservoir for some of the best ideas that we’ve implemented over the past 3 years in meeting the NHSC’s goals and HRSA’s commitments to the President and the nation to invest these resources as effectively as possible. And we very much hope that will continue as we strive in the years ahead to retain the dedicated clinicians who have chosen to begin their careers with us.

The program has really undergone what you might call an extreme makeover in a very short time.

What was three years ago a modest and not terribly user-friendly program that offered $50,000 in loan repayment support to a few hundred clinicians a year has grown with your help into a much easier, more flexible and rewarding inducement to service.

Through rolling admissions, and more generous site approval rules, we have made it easier than ever to join the Corps. And we now offer up to $170,000 for five years of service – all of it tax-free.

As this Council first pointed out in 2009, this effectively improves a clinician’s annual salary, because he or she is not paying off debt in after-tax income. It’s one reason that more than 1,300 clinicians extended their service contracts with us last year.

So, in addition to being much more user-friendly, today’s NHSC also is much more competitive in an open job market that is short on primary care clinicians.

CMS and HRSA are working together with Children’s Hospitals, GME recipients and Teaching Health Centers – in order to see how federal resources are being used to produce primary care providers. And HRSA’s National Center for Heath Workforce Analysis has several studies underway to further clarify and project the numbers across primary care professions and regions of the country.

So, recruitment will continue to be a challenge for the NHSC going forward. But given the unpredictability of budget allocations over time I think we all know that retention is – and always has been – an essential part of meeting our long-term needs.

We are fortunate that 82 percent of Corps providers continue to practice in shortage areas after they fulfill their service commitments. But we think there is still room for improvement, and we’re trying to get a better sense of the longer term component.

So we are very much interested in hearing your best thinking on this – including proposals for possible pilot programs and best practices for promoting continued service in underserved areas.

We, of course, are eager to hear later in the conference what Don Pathman has learned in his long-awaited retention study about the challenges in primary care, the programmatic designs to address them, and strategies for improving the levels on which this Administration has placed high priorities. It’s important that people clearly get the link between primary care and the health of individuals and communities.

Secretary Kathleen Sebelius said recently:

"When you don't have access to primary care, small health problems grow into big ones. Chronic conditions that could be managed spiral out of control … Thanks to the National Health Service Corps, more Americans can see a doctor and get the health care they need. The investments we made are improving health, creating access to care, (and) fueling economic activity nationwide.”

With the continued implementation of the Affordable Care Act in 2012, we have other opportunities to close gaps in service and come closer to realizing the vision of the President and Congress for a high-performance health care system.

As just one example, our grantees in the health center network have boosted the number of patients they serve to an all-time high of 19.5 million. They also have added 18,600 full-time staffers and increased their medical complement by 25 percent to 46,000 clinicians in the past two years.

Obviously, sustaining the growth in access to health care services envisioned by the ACA will require us to further bolster the primary care workforce and retain the clinicians we have today.

So under our Site Partnership Initiative, we are actively promoting the NHSC to our 1,100 health center grantees – who operate some 8,500 clinics nationwide – and we’re fast approaching the point of having all of our health centers in the NHSC site system. Similarly, we have more than tripled the number of Indian Health Service sites from 120 a few years ago to over 400 today – an incredibly important focus that the NHSC staff and leadership really stepped up to make happen with the IHS.

As you know, we have eliminated the site application requirement for all health centers – and part of the growth I just mentioned is a direct result. But we’ve gone further in our Bureau of Primary Health Care in promoting the NHSC to our health center grantees.

Today, 56 percent of NHSC sites are health centers, and 46 percent of our field strength practices in them.

With more than 17,000 NHSC rural and urban sites already approved nationwide, we stand to leap ahead in the next few years in terms of service opportunity locations for our clinicians. I do a lot of site visits to health centers, and I can tell you that it’s rare today to find one that doesn’t have at least one NHSC clinician on staff. It’s a question I always ask, and our grantees are enthusiastic in their endorsements of our clinicians.

And as I make these site visits, I’m often impressed by the diversity I encounter in our NHSC ranks.

That diversity helps HRSA reach all of the goals of its Strategic Plan, which are to:

Improve access to quality health care and services;

Strengthen the healthcare workforce;

Build healthy communities; and

Improve health equity.

Regarding that last goal, improving health equity, the staff from BCRS can tell you more as the day goes along about our success in achieving almost enviable diversity among our clinicians in the field.

This is mostly a function of our helping to facilitate homegrown talent – particularly in rural communities – and by increasing the range of service locations and bringing more people in underserved communities into contact with Corps clinicians. Of course, it also speaks to the diligence of our NHSC Ambassadors, alumni, the Council and our site partners.

Minorities comprise more than 25 percent of the U.S. population, but they represent only about 10 percent of the physician workforce, and just 7 percent in the nursing, dentistry and psychology professions.

It has been repeatedly borne out in the research that minority clinicians, generally, are more inclined to practice in underserved communities; and that patients are best served by health professionals who are conversant in their cultural backgrounds and primary languages.

So it has to be considered good news that about a third of our current Corps members are self-reported minorities. Hispanic clinicians, for example, represent about 15 percent of our field strength. So the NHSC is way ahead in minority representation compared to the overall healthcare workforce.

In other words, we are more than meeting our strategic goal here – and the question becomes: what are we learning here that could inform our work in other programs?

The Obama Administration is invested in developing this workforce, as evidenced by the Affordable Care Act’s support of educational programs for minority and disadvantaged students. HRSA alone made grants last year of $112 million for …

Scholarships for Disadvantaged Students;

the Centers of Excellence and Health Careers Opportunities programs; and

The additional support for these programs works to address disparities that have spanned decades – but I think it’s safe to say that the NHSC is one of the most visible and noteworthy of the Administration’s efforts … for the simple fact that it regularly attracts so much media attention.

Now, HRSA is working to restructure many of its other training programs -- including Title VII and VIII -- to make them more competitive, to promote interprofessional education and collaborative practice, and to encourage service to the underserved.

HRSA also plans in the year ahead to pursue collaboration with the National Governors Association on a project to assess ways to strengthen the health care workforce and access to primary care services, and on others to measure state-level workforce supply and training capacity.

In a very real sense, the NHSC and the health centers have been carrying the flag in visibly advancing the strategic goals of HRSA and the Affordable Care Act. But we are now at the stage that we are moving on all fronts, across all agencies of HHS. I will leave it to staff to tell you more about this, but 2012 is going to see an even more concerted effort on workforce that includes HRSA, CMS, AHRQ, the Assistant Secretary for Planning and Evaluation, and others.

The entire compliment of the workforce – from frontline providers to psychologists and others – is the linchpin in improving access, quality, and patient-centered, team-based practice.

And we‘re paying particular attention to one population to help meet our health professions workforce needs.

As is the case with so many HRSA programs, the National Health Service Corps sustains jobs – durable jobs in an expanding economic sector. And President Obama recently announced two new initiatives concerning military veterans – as he strongly believes that our vets deserve a solid glide path to meaningful employment.

So he has issued a challenge to the health centers to hire at least 8,000 veterans in the next 3 years – with a particular focus on those with backgrounds as military medics and corpsmen. On a parallel track, the President also has directed HRSA to give priority in awarding grants in support of physician assistant and nursing programs to universities and colleges that help train vets for those careers.

Now, let me just end with a word about data…

A major limitation for all of us engrossed in this effort has been the historic lack of health care workforce data, particularly at the regional and state level. I like to refer to it as operating in a data-free zone, which places the entire system at a disadvantage in forecasting health professions shortages.

The debate in policy circles over what to do about these shortages is far from over, and considerable misinformation continues to flourish in the absence of hard data.

We know from the World Health Organization, for example, that 57 countries are facing severe health workforce shortages, and that the problem is being exacerbated by a “brain drain” as trained clinicians migrate to fill vacancies in wealthier, industrialized countries (like the U.S.) that have developed workforce shortages of their own.

Addressing that is the principle aim of the WHO Global Code of Practice on International Recruitment of Health Personnel adopted at the 63rd World Health Assembly in May 2010 – an effort now partially housed within HRSA at the National Center for Health Workforce Analysis, and within HHS in the Office of Global Affairs.

So we now see a convergence of interests – local, state, federal and international – on these questions of workforce supply that will roll forward in 2012.

The Center itself expects to release at least five major reports in the coming year – including a state-level workforce database sometime next fall – that will provide reliable, actionable projections out to the year 2020 across a broad range of health professions. This will build on our Area Resource File, which already has a tremendous amount of data down to the county level, and which we now make available free of charge.

We also made significant progress in our thinking about shortage designation through the work of the HPSA/MUA Negotiated Rule Making Committee.

It’s against this backdrop that we look to you, as one of the nation’s most knowledgeable bodies on these issues, for guidance on how best to position the National Health Service Corps to address our critical primary care workforce needs.

Again, thank you for inviting me here today – and for your service on the National Advisory Council during this unprecedented time.